Treatment of Liver Fibrosis Due to Schistosomiasis
Treat all patients with schistosomal liver fibrosis with praziquantel in sufficient dosage and duration to eradicate the organism, as this is the only intervention that can prevent progression and potentially reverse early-stage fibrosis. 1
Primary Treatment Approach
Antiparasitic Therapy
- Praziquantel is the treatment of choice for schistosomiasis due to its efficacy, ease of administration, limited side effects, and low cost 2
- Administer appropriate antiparasitic therapy in sufficient dosage and duration to completely eradicate the organism 1
- Most individuals clear schistosomiasis with a single course of therapy, but repeat doses cure the majority of patients in whom eradication does not occur after the initial dose 2
- Immunosuppressive agents have no role in schistosomal liver disease and should not be used 1
Goals of Antiparasitic Treatment
- Primary goal: Complete parasite eradication, which reduces the likelihood of chronic complications including advanced hepatic fibrosis 2
- Secondary goal: For patients with persistent or recurrent infection, egg burden reduction lowers the risk of hepatic fibrosis progression 2
- Mild to moderate hepatic fibrosis results from the immune response to schistosome eggs deposited in portal venules and can reverse with successful treatment 2
Post-Treatment Monitoring
Ultrasound Follow-up
- Repeat abdominal ultrasound at 1 year post-treatment to assess for improvement in hepatic fibrosis parameters 3
- Expected improvements include decreased left liver lobe length, decreased spleen size, and reduced portal vein diameter ratios 3
- Parameters of hepatic fibrosis show significant improvement after treatment, although some indices may not return to normal levels 3
Screening for Coinfections
- Test for endemic coinfections (Salmonella, HBV, HCV, HIV) as targeted treatment may alter the aggressiveness of underlying disease or sequelae 1
- This is particularly important as concomitant cirrhosis from viral hepatitis makes ultrasound assessment of periportal fibrosis unreliable 4
Management of Advanced Fibrosis and Portal Hypertension
Critical Distinction
- Advanced liver fibrosis and portal hypertension due to chronic schistosomiasis are irreversible, even with successful parasite eradication 2
- Variceal bleeding is the primary cause of death in hepatic schistosomiasis 2
Portal Hypertension Management
- Manage portal hypertension according to guidelines for cirrhosis 1
- Beta-blocker prophylaxis or endoscopic banding/sclerotherapy are first-line interventions to reduce variceal bleeding risk 2
- For recalcitrant bleeding, surgical options include splenectomy with esophagogastric devascularization or selective shunts such as distal splenorenal shunt 2
- Transjugular intrahepatic portosystemic shunt (TIPS) is a less invasive, reversible alternative for refractory cases 5
Important Caveats
- Avoid nonselective shunt surgery (proximal splenorenal or TIPS in some contexts) as hepatic synthetic function remains normal in schistosomiasis, and procedures reducing portal pressure may cause hepatic impairment 2
- Risk of encephalopathy after shunt surgery is higher in schistosomiasis patients than in those with cirrhosis 2
Ongoing Surveillance
Kidney Disease Monitoring
- Monitor patients with hepatic fibrosis from schistosomiasis for development of kidney disease 1
- Evaluate patients with history of schistosomiasis and elevated serum creatinine and/or hematuria for bladder cancer and/or urinary obstruction 1
Hepatocellular Carcinoma Surveillance
- While ultrasound is the recommended surveillance modality for HCC in most chronic liver disease, its utility may be limited in schistosomal fibrosis depending on liver visualization quality 1